Care pathways for pregnant women with COVID – 19

Since the onset of the 2019 coronavirus (COVID-19) outbreak, concerns about the virus’ impact on pregnancy have increased. However, there has been little professional consensus on how best to manage pregnancy during the pandemic given the limited data currently available.

A recent review published in the magazine Global challenges in October 2020, it summarizes what is currently known about treating COVID-19 during pregnancy, and offers recommendations on how the health professions could better manage pregnant COVID-19 patients in the future.

Diagnosis of COVID-19 in pregnancy

The diagnosis of COVID-19 in pregnant women should be based on usual symptoms such as fever or cough and confirmed by viral and imaging tests. The test is indicated for those presenting with these symptoms or a history of contact with a known or suspected COVID-19 case and is conducted using real-time reverse transcriptase polymerase chain reaction (RT-PCR) via exchange samples.

With throat swab specimens, this test is approximately 90% sensitive but can produce many false positives, depending on the setup. Its positive predictive value (PPV) ranges from about 47% to about 96%. Greater accuracy would be possible with high throughput sequencing, but this would require more time and specific setup.

Another alternative is the serological test (via blood samples), which detects the presence of IgM and IgG (antibody) responses to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the pathogen that causes COVID- 19. This could identify both asymptomatic individuals and those who have had the virus and recovered. A rapid point-of-care lateral flow immunoassay is now available, with results within 15 minutes. Tests for IgM antibodies identify a current or very recent infection and decrease over time. They only collect half of the infected cases, but they are specific for about 90%. IgG indicates a past infection and increases over time.

Imaging tests in pregnancy

For a pregnant woman suspected of having this infection – or indeed, any pregnant woman hospitalized in an area with a high prevalence of COVID-19 – the researchers recommend a low-dose chest CT scan to increase detection rate and ensure minimal fetal impact.

The main findings of chest CT scan present in about 70% and about 80% of pregnant women with COVID-19 include ground glass opacity, insane flooring style, and consolidation. Compared to the RT-PCR test, chest CT scans are 97% sensitive, with a PPV of 65%, but not specific. Unpublished research by current authors confirms this finding.

Treatment of COVID-19 in pregnancy

Researchers recommend quarantine for SARS-CoV-2 infected pregnant women, rather than self-care at home. Discharge criteria include a normal temperature for three or more days, marked improvement in respiratory symptoms, resolution of chest imaging signs, two consecutive negative RT-PCR tests, and no other conditions associated with pregnancy.

General management of the disease includes rest, good nutrition, and careful monitoring of respiratory symptoms, heart and lung function. Other indices of inflammation, such as PCR and chest imaging, should be monitored, along with oxygen administration as needed. Traditional Chinese herbs can also help with mild COVID-19.

Antiviral therapy

Remdesivir can be effective and safe. Chloroquine and hydroxychloroquine also have “apparent efficacy”. However, high doses of chloroquine can cause systolic hypotension, which could cause hemodynamic changes during pregnancy due to compression of the inferior vena cava and aorta by the pregnant uterus.

Other antivirals known to be safe and effective in pregnancy include oseltamivir or zanamivir, which are recommended for the treatment of influenza in pregnancy by the American College of Obstetricians and Gynecologists (ACOG). The researchers say more data is needed for the use of these drugs in pregnancy, especially with regards to heart complications.

Severe COVID-19 in pregnancy

Severe COVID-19 is characterized by deterioration of vital signs, shock, organ failure, low lymphocyte counts, high levels of inflammatory markers, or signs of rapidly progressing lung disease. This indicates intensive care admission (ICU) and possibly invasive mechanical ventilation, to maintain adequate oxygen saturation. Support of renal function or haemopurification, where necessary, is effective in seriously ill pregnant patients.

Pregnant patients before 28 weeks

Before the 28th week of pregnancy, supportive and antiviral therapy are used to promote recovery and continuation of the pregnancy to term, provided that both mother and baby are in good condition. Close fetal monitoring and administration of corticosteroids are required for fetal lung maturation. A progressive disease or other obstetric indication may indicate childbirth.

Prevention of COVID-19 in Pregnancy

Pregnancy requires family care and medical attention, making quarantine difficult. Therefore, security is a priority. This involves self-isolation at home unless medical reasons prohibit it and staying away from any family member with suspected or confirmed infection. Wearing the mask and washing hands is mandatory to reduce the chances of infection.

Daily disinfection of high-contact surfaces such as furniture, doorknobs, handles, computers, cell phones, and toilets are other recommendations provided by researchers to prevent infection during pregnancy.

To prevent infection during obstetric examinations in hospitals, only mandatory examinations should be done, identifying each patient’s schedule and prioritizing home visits. This should be complemented by online consultations or telemedicine, with remote monitoring of the fetal heart rate. Hospital visits should be by appointment using other anti-infection precautions and avoiding crowding in waiting areas.

Childbirth in pregnancy positive for COVID-19

Having COVID-19 by itself is not an indicator for anytime delivery. Stable patients between 28 and 34 weeks can expect to continue pregnancy, even with pneumonia if they have no other complications, with no evidence of infection or fetal abnormalities.

Timely delivery should be accelerated if the mother has progressive or systemic lung disease with COVID-19 or for obstetric indications. Cesarean delivery should be chosen according to obstetric indication, or in case of severe COVID-19, according to the patient’s request, or any other contraindication to normal delivery.

Precautions during delivery

With all standard precautions in place, delivery should be done in isolation wards with negative pressure airflow. To relieve the necessary pain, spinal anesthesia or, for very ill patients, general anesthesia with intubation is preferred.

For caesareans, general or epidural anesthesia can be used. The former could cause viral spread through the body, worsening of the disease or fetal deterioration, but the latter can cause hypotension.

After giving birth

Potential complications during the puerperium include an increased risk of infection, worsening clinical severity, and problems with breastfeeding. The researchers point to the U.S. Centers for Disease Control and Prevention (CDC) guidelines for breast drafting, with milk given to the baby by a healthy individual. Once the mother is recovering well and other criteria for removal from quarantine are met (as above), she can be discharged.

Management of newborns

Very few researchers think, based on the available evidence, that newborns can be infected before or during delivery. However, care should be taken to minimize the risk by promptly cutting the cord, cleaning the mouth and nose, and drying the baby to remove maternal body fluids.

Diagnosis in infants may be more accurate with chest serology and CT than with viral RNA testing. IgM antibodies appear 3-5 days from the onset of infection. Their appearance can signal an intrauterine or perinatal infection. Positive serologic infants should be isolated and diagnosis confirmed and admitted to neonatal intensive care if necessary.

Follow-up after discharge

Since some patients have had positive PCR tests or persistent lesions after discharge, a rigorous follow-up is also recommended for pregnant women, in another unit for another 14 days. This will also protect them from other infections given the lower number of T cells observed.

Conclusion

Researchers establish general and special measures to prevent and treat SARS-CoV-2 infection in pregnancy. This guide will encourage fewer pregnancy-related complications and better results.